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Patient safety incidents – what to do after the event

2014· article· en· W2312396520 on OpenAlexaffabout
Christina Godfrey, K. Sear

Bibliographic record

VenueInternational Journal of Evidence-Based Healthcare · 2014
Typearticle
Languageen
FieldHealth Professions
TopicPatient Safety and Medication Errors
Canadian institutionsQueen's University
Fundersnot available
KeywordsCINAHLPsycINFOMEDLINEPatient safetyDebriefingCochrane LibraryGrey literatureHealth carePsychologyMedicineComputer scienceMedical educationNursingPsychological intervention

Abstract

fetched live from OpenAlex

Background: Following a patient safety incident, patients and families need disclosure and reconciliation, practitioners need debriefing, and the organization needs to implement changes to prevent further errors. In order to substantiate the Canadian Incident Analysis Framework, the Canadian Patient Safety Institute (CPSI) invited Queen's Joanna Briggs Collaboration (QJBC) to work collaboratively with them to provide a synthesis of the current literature on the frameworks, models or tools that address patient safety incident management. Objective: To perform a mapping review of the international literature focused on frameworks, models or tools for patient safety incident management across the continuum of care. Methods: We followed Joanna Briggs Institute method of synthesis. A 3-step approach was used to search the peer-review literature: 1) initial search of MEDLINE and CINAHL; 2) detailed search across all databases using all keywords and index terms; 3) hand search the reference lists of includedpapersto locate additional studies. Targeted databases included: CINAHL; Medline; EMBASE; PsycINFO; AMED; Cochrane; Web of Science, Ageline; GlobalHealth; and Social Sciences Abstracts. Search strategies were tested for sensitivity and specificity by QJBC Library Scientist using the Peer Review of Electronic Search Strategies (PRESS) methodology developed by Canadian Agency for Drugs and Technologies in Health. Results: The search located 4,413 citations that provided 21 papers. Publication dates spanned 1999–2012 and included 10 theoretical papers, seven descriptive studies, three reviews, and one qualitative study. Thirteen models, four frameworks and four tools were identified. Discussion: A range of approaches were described including psychological and cognitive frameworks, statistical models, and human factors approaches. Only one model had been formally evaluated and implemented in several settings. Conclusion: To advance our knowledge in this area existing models, frameworks and tools need to be evaluated and implemented. Further research would be beneficial.

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.

How this classification was reachedexpand

Full frame distilled prediction

Teacher imitation

Not calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.

metaresearch head score (Codex)0.003
metaresearch head score (Gemma)0.003
Version: codex-gemma-dda1882f352aValidation status: machine_predicted_unvalidated
Candidate categoriesnone
Consensus categoriesnone
DomainCandidate signal: none · Consensus signal: none
Study designCandidate signal: Observational · Consensus signal: none
GenreCandidate signal: Empirical · Consensus signal: none
Teacher disagreement score0.595
Threshold uncertainty score0.622

Codex and Gemma teacher scores by category

CategoryCodexGemma
Metaresearch0.0030.003
Meta-epidemiology (narrow)0.0000.000
Meta-epidemiology (broad)0.0000.000
Bibliometrics0.0000.000
Science and technology studies0.0000.000
Scholarly communication0.0000.001
Open science0.0010.000
Research integrity0.0000.001
Insufficient payload (model declined to judge)0.0010.000

Machine scores (provisional)

The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.

Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.

Opus teacher head0.131
GPT teacher head0.471
Teacher spread0.339 · how far apart the two teachers sit on this one work
Validation statusscore_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from it

Classification

machine, unvalidated

Machine predicted; a candidate call from one teacher head, not a consensus.

The models applied no category: nothing in the taxonomy fit this work.
Study designObservational
Domainnot available
GenreEmpirical

How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".

Quick stats

Citations0
Published2014
Admission routes2
Has abstractyes

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